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Devoted GIVEBACK Tennessee (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Devoted GIVEBACK Tennessee (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Devoted GIVEBACK Tennessee (HMO) in 2025, please refer to our full plan details page.
Devoted GIVEBACK Tennessee (HMO) is a HMO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Knoxville. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that Devoted GIVEBACK Tennessee (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Devoted GIVEBACK Tennessee (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Devoted GIVEBACK Tennessee (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $147.70. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $590.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $6700.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Devoted GIVEBACK Tennessee (HMO) plan has an enhanced alternative drug benefit. The plan has a deductible of $590.00. After the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy you use. For example, standard generic drugs have a 25% coinsurance, while preferred generic drugs have a $10 copay. Once your total drug costs reach $2000.00, you enter the catastrophic coverage phase where you pay nothing for covered drugs.
Additional Benefits
The Devoted GIVEBACK Tennessee (HMO) plan provides coverage for a wide range of healthcare services. This includes inpatient and outpatient hospital care, with varying copays, as well as services like primary care, hearing, vision, and dental. The plan also covers emergency services, ambulance services, and home health services. Additionally, there are benefits for preventive services, and durable medical equipment with coinsurance.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered. For days 1-5, the copay is $375, and for days 6-90, there is no copay. Additional Days for Inpatient Hospital-Acute are covered, but Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute, as well as Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for outpatient hospital services with a copay between $0 and $475, observation services with a $375 copay, and ambulatory surgical center services with no copay. Outpatient substance abuse services have a $45 copay for individual and group sessions, and outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Devoted GIVEBACK Tennessee (HMO) plan, with a $65 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with prior authorization required for all ambulance services. Ground ambulance services have a copay of $0-$300, while air ambulance services have a 20% coinsurance. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Devoted GIVEBACK Tennessee (HMO) plan. Emergency Services has a $125 copay, while Urgently Needed Services have a copay between $0 and $55; Worldwide Emergency Transportation has a $300 copay and 20% coinsurance, while Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $125 copay.
Primary Care See details
Primary Care Physician Services, Chiropractic Services, Occupational Therapy Services, Physician Specialist Services, Mental Health Specialty Services, Other Health Care Professional, Psychiatric Services, Physical Therapy and Speech-Language Pathology Services, Additional Telehealth Benefits, and Opioid Treatment Program Services are covered. Chiropractic services have a $20 copay, while occupational therapy, physician specialist services, individual and group mental health sessions, individual and group psychiatric sessions, and opioid treatment program services have a $45 copay. Physical therapy and speech-language pathology services have a copay between $45 and $50, and additional telehealth benefits have a copay between $0 and $45. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
The Devoted GIVEBACK Tennessee (HMO) plan covers preventive services, including Medicare-covered preventive services, annual physical exams, health education, weight management programs, alternative therapies, nutritional/dietary benefits, fitness benefits, Home and Bathroom Safety Devices and Modifications, Kidney Disease Education Services, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a Welcome Visit. In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Therapeutic Massage, Adult Day Health Services, Home-Based Palliative Care, In-Home Support Services, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Enhanced Disease Management, Telemonitoring Services, Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline), and Counseling Services are not covered.
Hearing Services See details
Hearing Services are covered by the Devoted GIVEBACK Tennessee (HMO) plan, including Routine Hearing Exams with a $45 copay for one exam every year and Fitting/Evaluation for Hearing Aid with no copay. Prescription Hearing Aids (all types) are covered with a copay between $599 and $899 for two hearing aids every year, but Prescription Hearing Aids - Inner Ear, Outer Ear, and Over the Ear are not covered, and OTC Hearing Aids are not covered.
Vision Services See details
Vision services with the Devoted GIVEBACK Tennessee (HMO) plan include coverage for eye exams with a $45 copay, eyewear with a combined maximum of $250 every year, and contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades with no copay or coinsurance. Routine eye exams are covered once per year.
Dental Services See details
Dental Services include coverage for Medicare Dental Services with a $45 copay, and other dental services with a $250 annual maximum. Oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery are covered. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and prior authorization is required. For Medicare Part B Insulin Drugs, there is a $35 copay and 20% coinsurance. Other Medicare Part B Drugs have a coinsurance between 0% and 20%, and Medicare Part B Chemotherapy/Radiation Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Devoted GIVEBACK Tennessee (HMO) plan, with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment is covered by the Devoted GIVEBACK Tennessee (HMO) plan. Durable Medical Equipment (DME) has a coinsurance between 20% and 35%, and Prosthetic Devices have a coinsurance between 0% and 20%; however, Durable Medical Equipment for use outside the home is not covered. Medical Supplies have a 20% coinsurance, and Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic services, diagnostic procedures/tests with a copay between $0 and $95, lab services with no copay, and outpatient X-ray services with no copay. Therapeutic Radiological Services have a coinsurance of at least 20%, and Diagnostic Radiological Services have a copay of at most $300.
Home Health Services See details
Home Health Services are covered under the Devoted GIVEBACK Tennessee (HMO) plan, with no copay or coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but none of the sub-services are covered by the plan. The plan does not list any copay or coinsurance information for Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Devoted GIVEBACK Tennessee (HMO) plan. There is no copay for days 1-20, and a $214 copay for days 21-100.
Other Services See details
Other Services are not covered, including acupuncture, over-the-counter items, meal benefits, Dual Eligible SNPs, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services. However, Other 2 benefits are covered.
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